Name: E-mail:
Spouse’s Name: Emergency Contact Phone Number:
If client is Minor - Parents’ Names:
Home Address:
City: State: Zip:
Mailing Address:
Home Phone (with area code): Work Phone (with area code):
Employer: City: Profession:
Birth Date: Referred by:
Primary Care Physician: City: Phone Number (with area code):
Check any of the following medications you are taking or have taken within the last 90 days:
Antacids Cortisone/Anti-inflammatories Lithium Antibiotic/Antifungal Heart Medications Oral Contraceptives Antidepressants High Blood Pressure Radiation Antidiabetic/Insulin Hormones Relaxants/Sleeping Pills Aspirin/Tylenol Inhalers Thyroid Chemotherapy Laxatives Ulcer Medications Recreational Drugs Specify: Other Specify:
Antacids
Cortisone/Anti-inflammatories
Lithium
Antibiotic/Antifungal
Heart Medications
Oral Contraceptives
Antidepressants
High Blood Pressure
Radiation
Antidiabetic/Insulin
Hormones
Relaxants/Sleeping Pills
Aspirin/Tylenol
Inhalers
Thyroid
Chemotherapy
Laxatives
Ulcer Medications
Recreational Drugs Specify:
Other Specify:
Check if you eat, drink, or use:
Alcohol
Distilled water
Refined sugars
Candy
At fast food restaurants regularly
Saccharine (artifical sweeteners)
Carbonated beverages
Fried foods
Chew tobacco
Cigarettes
Luncheon meats
Vitamins and/or Minerals
Coffee
Margarine
Check if you:
Diet often
Salt food without tasting
Are exposed to chemicals at work
Do not exercise regularly
Are under excessive stress
Are exposed to cigarette smoke
List all medications taken within the past 90 days:
List all supplements:
Do you have a history of any of the following:
High blood pressure
Low blood pressure
Elevated blood sugar levels
Low blood sugar levels
Family history of diabetes:
Father’s side:
Mother’s side:
Both:
Family history of cancer. If yes, what type:
Any hereditary condition. If yes, describe.
Heart problems. If yes, what type:
Please list below the five main complaints you have in the order of importance:
1.
2.
3.
4.
5.
List any allergies (food, chemicals, medications, supplements, environmental, pets):
Please read carefully before submitting or signing:
I hereby authorize Gloria Gilbčre, and her representatives, to act on my behalf concerning the corrective, non-drug programs offered to achieve holistic health. I specifically authorize her to evaluate my health concerns and to recommend the appropriate nutritional and detoxification programs, lifestyle and environmental modifications necessary.
I warrant that all information submitted for evaluation is submitted by me and is true to the best of my knowledge. I also attest that I am disclosing all medical information including any medical diagnosis, physicians’/therapists’ names and contact information, any drugs, herbs, supplements, allergies, or therapies I am currently having or have had within the past 90 days.
I recognize that the approach (s) recommended by Gloria Gilbčre are non-medical. I also recognize that she will evaluate my condition so she can make appropriate personalized wellness protocols suited specifically for me. I, and any family members, heirs, or other parties, hereby hold Gloria Gilbčre, et al harmless in any way. I understand it is my responsibility and choice to follow the wellness protocols recommended. The programs recommended by Gloria Gilbčre are designed to allow the body to have the necessary natural means to promote health and healing and boost my body’s immune system by implementing nutrition-based medicine, alternative therapies as appropriate, lifestyle modifications and nutraceuticals or other natural healing modalities. I also understand that as a client of Gloria Gilbčre, division of Gloria E. Gilbčre, LLC, twenty dollars of my consulting fee will be applied to a one-time membership fee as part of a Private Healthcare Membership Association of The Institute for Wholistic Rejuvenation, of which Gloria Gilbčre is the health care director
Client’s Name: E-mail: Date:
If client is minor, parent/guardian must acknowledge below:
Name of Minor:
Name of Parent/Guardian
By clicking submit, you are confirming that the information contained above is true and correct, and acknowledge that you are providing an electronic signature. You also attest that you are submitting this document solely as a client, on this and any subsequent visits (in person, by e-cam or telephone), and solely on your own behalf and not as an agent of any agency, people, organization or parties. You also attest that any person or persons with you at this time and any future consultation by any means are strictly present to accompany you at your request and not as an agent or other representative in any way whatsoever.
***IMPORTANT***
Before you submit online or mail, print all your forms, You will need to mail us a close up photo taken within the past 30 days -. If you have a digital camera, you may send to healthmatterstore@frontier.com
©2011 Gloria E. Gilbčre, LLC, Institute for Wholistic Rejuvenation, a Private Healthcare Membership Association
I, Gloria Gilbère, am neither a medical or naturopathic physician, and do not hold myself out as one. I am trained as a doctor of natural health and wholistic nutrition, a certified dietary supplement counselor, and as a clinical and classical homeopath. As a client, you will be informed of the natural approaches necessary for a lifestyle of healthy living**. The recommendations given are not a substitute for conventional medical treatment; they are natural, non-drug protocols. I do not diagnose, treat or cure, but rather work within holistic, integrative natural protocols to achieve health. It is my goal to assist you in dealing with the underlying causes of your condition, not merely the effects – accomplishing a natural overall approach to your health and quality of life. For any medical problem, it is important that you disclose to my office the name of your physician, any allergies, and any medications you are taking, or have taken within the past 90 days.
At this time, most insurance companies do not pay for nutritional, environmental or wellness healthcare consulting. Please SAVE ALL YOUR RECEIPTS, we do not bill or deal with insurance companies or year end summaries. It is your responsibility to submit or deal with your insurance carrier if your policy covers nutritional and wellness services. Payment is due at time of service, no exceptions – we accept Visa and Master Card.
If we should have to use legal or collection means to collect on your account, you agree that you will be responsible for all charges/fees incurred by us. A finance charge of 2.5 percent per month will be added to all balances beyond 15 days.
Name of Minor: Age:
Name of Parent/Guardian: Date:
A doctor of natural health recognizes the healing power of nature, incorporating diet, exercise, pure water, rest, sunlight and fresh air. A doctor of natural health prepares each student to educate and empower the public to actively choose a healthy lifestyle. A doctor of natural health does not perform invasive procedures, diagnose, treat illness, or prescribe drugs. He / She focuses the clients attention through education to attain, fine-tune, and maximize his / her own homeostasis. This holistic approach incorporates health promotion by giving equal consideration to body, mind and spirit. It is a proactive model rather than a reactive (allopathic) model of health care.
Holistic Nutrition, natural health and rejuvenation focuses on health through education rather than diagnosis. The training prepares each practitioner with a solid foundation in nutrition counseling including nutraceuticals, minerals, homeopathic, and herbals, as well as organic "living foods". Wholistic Rejuvenation counseling includes natural detoxification methodologies to assist the body in reducing its overall toxic burden; facilitating natural healing processes at a return to homoestasis by implementing nutrition-based medicine principles.
Copyright 2011 Gloria E. Gilbere, LLC, Institute for Wholistic Rejuvenation, a Private Healthcare Membership Association
Patient Name: Email: Date:
Weight: Height: Eye Color:
Rate each of the following symptoms based upon your typical health profile for the past 30 days.
Point Scale:
0 = Never or almost never have the symptom 1 = Occasionally have it; effect is not severe 2 = Occasionally have it; effect is severe 3 = Frequently have it; effect is not severe 4 = Frequently have it; effect is severe
HEAD:
Headaches: 0 1 2 3 4
Faintness: 0 1 2 3 4
Dizziness: 0 1 2 3 4
Insomnia: 0 1 2 3 4
Total:
EYES:
Watery or itchy eyes: 0 1 2 3 4
Swollen, reddened or sticky eyelids: 0 1 2 3 4
Bags or dark circles under eyes: 0 1 2 3 4
Blurred or tunnel vision (Does not include near- or far-sightedness): 0 1 2 3 4
EARS:
Itchy ears: 0 1 2 3 4
Earaches, ear infections: 0 1 2 3 4
Drainage from ear: 0 1 2 3 4
Ringing in ears, hearing loss: 0 1 2 3 4
NOSE:
Stuffy nose: 0 1 2 3 4
Sinus problems: 0 1 2 3 4
Hay fever: 0 1 2 3 4
Sneezing attacks: 0 1 2 3 4
Excessive mucus formation: 0 1 2 3 4
MOUTH/THROAT:
Chronic coughing: 0 1 2 3 4
Gagging, frequent need to clear throat: 0 1 2 3 4
Sore throat, hoarseness, loss of voice: 0 1 2 3 4
Swollen or discolored tongue, gums, lips: 0 1 2 3 4
Canker sores: 0 1 2 3 4
SKIN:
Acne: 0 1 2 3 4
Hives, rashes, dry skin: 0 1 2 3 4
Hair loss: 0 1 2 3 4
Flushing, hot flashes: 0 1 2 3 4
Excessive sweating: 0 1 2 3 4
HEART:
Irregular or skipped heartbeat: 0 1 2 3 4
Rapid or pounding heartbeat: 0 1 2 3 4
Chest pain: 0 1 2 3 4
LUNGS:
Chest congestion: 0 1 2 3 4
Asthma, bronchitis: 0 1 2 3 4
Shortness of breath: 0 1 2 3 4
Difficulty breathing: 0 1 2 3 4
DIGESTIVE TRACT:
Nausea, vomiting: 0 1 2 3 4
Diarrhea: 0 1 2 3 4
Constipation: 0 1 2 3 4
Bloated feeling: 0 1 2 3 4
Belching, passing gas: 0 1 2 3 4
Heartburn: 0 1 2 3 4
Intestinal/stomach pain: 0 1 2 3 4
JOINTS/MUSCLE:
Pain or aches in joint: 0 1 2 3 4
Arthritis: 0 1 2 3 4
Stiffness or limitation of movement: 0 1 2 3 4
Pain or aches in muscles: 0 1 2 3 4
Feeling of weakness or tiredness: 0 1 2 3 4
WEIGHT:
Binge eating/drinking: 0 1 2 3 4
Craving certain foods: 0 1 2 3 4
Excessive weight: 0 1 2 3 4
Compulsive eating: 0 1 2 3 4
Water retention: 0 1 2 3 4
Underweight: 0 1 2 3 4
ENERGY/ACTIVITY:
Fatigue, sluggishness: 0 1 2 3 4
Apathy, lethargy: 0 1 2 3 4
Hyperactivity: 0 1 2 3 4
Restlessness: 0 1 2 3 4
MIND:
Poor memory: 0 1 2 3 4
Confusion, poor comprehension: 0 1 2 3 4
Poor concentration: 0 1 2 3 4
Poor physical coordination: 0 1 2 3 4
Difficulty in making decisions: 0 1 2 3 4
Stuttering or stammering: 0 1 2 3 4
Slurred speech: 0 1 2 3 4
Learning disabilities: 0 1 2 3 4
EMOTIONS:
Mood swings: 0 1 2 3 4
Anxiety, fear, nervousness: 0 1 2 3 4
Anger, irritability, aggressiveness: 0 1 2 3 4
Depression: 0 1 2 3 4
OTHER:
Frequent illness: 0 1 2 3 4
Frequent or urgent urination: 0 1 2 3 4
Genital itch or discharge: 0 1 2 3 4
Are you sensitive/allergic to fragrances (perfume, air fresheners, fabric softeners, candles, etc.)? If so, list:
Do you use a self-cleaning oven? Yes No
Do you color your hair? Yes No Do you permanent wave your hair? Yes No Do you wear acrylic nails? Yes No
Do you use clothes dryer fabric softener sheets? Yes No
Do you use conventional window/glass cleaners? Yes No
Are you sensitive/allergic to refueling your car? Yes No
How old is your car? How old is your home?
Does your home have standing water or visible mold? Yes No
Have you recently painted any room in your home or office? Yes No
Is the carpet in your home or office newer than 2 years? Yes No
What type of cook stove do you have? (check which one) Natural gas, electric, wood, propane, solar power
What type of heat do you have in your home? (check which one) Natural gas, electric, radiant, wood, propane, solar power, hot water, baseboard heat
Do you use a microwave oven at home or office? Yes No
Are your mattresses newer than 4 years? Yes No If so, when were they purchased?
Do you use fragranced spray room fresheners or plug-in fresheners? Yes No
Do you use carpet sprays for cleaning or deodorizing? Yes No
How many times per year do you travel by air?
Have you traveled outside the U.S.? Yes No If so, when was last trip:
Do you get symptoms of any of the following when exposed to any environmental factors? Yes No (If yes, check those that apply): Headaches Stuffy nose Sinus pain Muscle aches Blurred vision Trouble concentrating Loss of balance Sore throat Cough Sneezing
Headaches
Stuffy nose
Sinus pain
Muscle aches
Blurred vision
Trouble concentrating
Loss of balance
Sore throat
Cough
Sneezing
Are you exposed to chemicals in your work/profession? Yes No If so, what type?
Has your home or office been remodeled within the past 4 years? Yes No If so, when:
If you use a computer, how many hours average per day do you use it?
If you commute to your office or place of business, how long is your commute in time? in miles round trip per day or total miles per week.
DENTAL HEALTH: How often do you regularly get your teeth cleaned by either a dentist or hygienist? When was the last time you had a professional teeth cleaning? Month: Year: Do you have any root canals? Yes No If so where: Do you have any silver (amalgam) fillings? Yes No If you’ve had silver (amalgam) fillings replaced, give Month: Year: Do you wear, or have you ever worn a night-guard? Yes No Are you allergic to epinephrine in local anesthetic? Yes No If so, what type of anesthetic can you tolerate? Does your tongue have a definite white coating? Yes No Have you had any extractions? Yes No If so, describe location of teeth and approximate year of extraction: Do you wear a partial or dentures? Yes No If so, which: Partial Dentures Have you been diagnosed with TMJ syndrome? Yes No Are you overly apprehensive about going to the dentist? Yes No Do you experience headaches, depression, anxiety or emotionally fragile systems after local anesthetic? Yes No (If yes, check those that apply): Headaches Depression Anxiety Emotionally Fragile
Have you had any dental implants? Yes No Have you ever had an allergic reaction either in the dental office or as a result of a dental procedure? Yes No If so, explain: Does your biological father have dentures? Yes No If so, at what age approximately did they receive them? Does your biological mother have dentures? Yes No If so, at what age approximately did they receive them? Did you have a lot of cavities as a child and adolescent? Yes No What type of product do you use to brush your teeth? Describe: Do you floss daily? Yes No Do you use toothpicks? Yes No Have you been told you have any form of gum (periodontal) disease? Yes No If so, describe: Have you ever had I.V. sedation? Yes No Was your experience positive? Yes No If not, explain: Does heart disease run in your family? Yes No Do inflammatory disorders fun in your family (Arthritis, Fibromyalgia, Gout, Lupus etc.) Yes No If so, describe condition and relationship: When was your last dental visit for restorative work? Month: Year: Do you have difficulty swallowing pills? Yes No Do you gag easily? Yes No Do you get nausea easily? Yes No Do you experience sinus infections? Yes No How Often? Do you experience migraine-type headaches? Yes No How Often? Who is your dentist? Dr.: City: State: Country:
Click the button below to submit this form. You should also print this as a backup and for your own personal records.
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